Sickle Cell Disease - Block 4 Flashcards
What is the difference betweent SCT and SCD?
SCT: Heterozygous inheritance of one HbA gene and one sickle gene (HbAS)
SCD: Homozygous HbS (HbSS)
What is the cause of SCD?
Gene mutation of b-subunits on hemeglobin (HbS)
What are the classifications of anemia?
Male: Hb <13
Women: Hb <12
Describe the patho of SCD?
- Oxygenated HbS is similar to normal RBC
- Deoxygenated HbS: reduce solubility and increased binding
- Polymeization: distortion of RBC and loss of deformability
- Sickled RBCs: increase viscisty and sludging
- Reoxygenated: polymer lost and return to normal shape
- Cycle: damage to cells, decreased membrane flexibility, and phospholipid rearrangement
- Irreversible sickled cell: decreased flow and increased vascular endothelial adherence
- Intravascular destruction: 10-20 days
How are newborns screened for SCD?
- Isoelectric finding
- High performance liquid chromatography
- Hb electrophoresis
- With + creening have 2nd test before 2 months of age to confirm
When is the onset of SCD in newborns?
4-6 month after birth due to prior presence of HbF (2a, 2y)
* 3-4 months RBC life
Lab findings of SCD in newborns?
- Low Hb (6-9)
- Elevated reticulocytes of 10-25%, platelets and WBC
- Normal MCV
- Sickle cell
Burden of SCD in children?
- Dacylitis before 1 YO
- Hb<7
- Leokocytosis w/o infection
- Rectilocytosis -> stroke and death
- Acute chest syndrome first 3 Y
- SCD + Asthma -> increaed frequency of ACS
Burden of disease in adults?
Decreased survival:
1. chest pain
2. ElevatedWBC
3. CV event
4. Renal failure
5. Proteinuria
6. Pulmonary HTN
What are the goals of SC tx?
Reduce hospitalization, mortality, and complications
Types of health maintenance of SCD?
- Immunization
- Invasive pneumococcal infection prevention
- Renal
- Pulmonary HTN
- Ophthalmological evaluation
- Stroke prevention
How should SCD patients recieve immunization?
Fall under anatomical or functional asplenia due to impair spleen function
How is invasive pnemococcal infection prevented?
Penicillin prophylaxis till 5 YO who pevent with HbSS or HbSb0-thal until they are completely vaccinated against Pneuococcal
* Pen V K+ 125 mg PO BID until 3YO, 250 BID till 5YO
- Erythromycin 20mg/kg/day
How do we screen for pulmonary hypertension?
- Noninvasive tests (Doppler or serum NT-pro-BNP) -> assess mortality
- Pulmonary function test
- Polycomnography
- Oxygenation assessment
- Thromboembolic dx
Indications for Doppler echo?
To screen for PAH and associated cardiac problems by age 8 with frequent cardiorespiratory sx
Recommended Q1-3Y
Tx for SCD-induced PAH?
Cardiac catheterization prior to tx:
Screenign and tx for renal complications from SCD?
Screen: proteinuria by age 10 and annually if negative
Tx: Initiate ACEI for adults with microalbuminuria (30-300) or proteinuria (>300) without apparent cause
Screenign for opthalmological complications from SCD?
Eye exam at 10 YO and rescreen Q1-2Y
Screenign and tx for stroke from SCD children?
Screening: transcranial doppler annually beginning age 2 until 16
Tx: Chronic transfusion therapy for stroke prevention in children with elevated TCD (>200 cm/s)
WHat is the purpose of HbF induction?
Increased HbF -> decreased RBC sickling and adhesion -> Less severe SCD and complications
Examples of HbF inducation tx?
- Hydroxyurea (Droxia, Siklos)
- L-Glutamine (endari)
- Voxelotor (Oxbyrta)
What is the MOA of hydroxyurea?
- Stimulates HbF production, reticulocyted, and intracellular HbF
- Cytotoxic -> stimulates erythropoisis in bone marrow
- Increase NO (vasodilation)
- Decrease RBC adhesion to endothelium
Who qualifies for hydroyurea tx?
Adults with SCD:
1. Three or more sicke cell associated mod-severe pain crises per year
2. SCD interferes with ADLs
3. Hx of severe or recurrent ACS
4. Severe symptomatic chronic anemia that affect ADL
5. Infants (9 months) with SCD
6. CKD on eyrthropien
Hydroxyurea brands or interchangable?
No
Hydroxyurea
DOsing, BBW
Dosing: renal dosing (<60) - 5-10mg/kg
* Admin at the same time everyday
* ANtineoplastic requires proper handeling
BBW bone marrow suppression (leukopenia, neutropenia, thrombocytopenia, anemia, decreased reticulocyte count)
* Reproductive tox
* Carcinogenic
MOA of L-Glutamine
Restores redox balance in oxidative stressed cell by NAD+ synthesis
* reduced pain episodes and hospitalizations
ADR of L-glutamine?
N, C, noncardiac chest pain, fatigue, musculoskeletal pain
Voxelotor
MOA, Indication, DDI, ADR
MOA: HbS polymerization inhibitor -> stabilized the oxygenated Hb state
Indication: ≥12YO
DDI: 1,500 mg taken once daily unless weight is under 40 kg; dose adjustment to 1,000 mg once daily in severe hepatic impairment
* CYP3A4 substrate
ADR: HA, D
What is the function of chronic transfusion?
Purpose: prevent primary and secondary stroke prevention and improve organ damage
Method: simple transfusion, manual and automated exchange
Benefit: increase normal HbA, decrease viscosity, limit volume
Cons: Iron overload, alloimmunization, volume overload, infection, reaction, hyperviscosity
How often are transfusions given?
3-4 weeks but is adjusted to maintain desired HbS levels
What is the transfusion goal?
- HbS concentration <30%
- absence of recurrent stroke for 2 years, Hbs <50%
How do we minimize the risk of transfusion?
- Hep A and B vaccine
- Blood screening (virus)
- Cross matched blood products (phenotyping)
- Avoid excess dietary iron